BILLING - Laserfiche WebLink

Home Browse Search

Pe60JM [ CO P STATE OF CALIFORNIA + STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA ��LIFOPPn COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY❑ O /SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT WM060TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) NAME OF OPERATOR DBA OR FACILITY ME Or �� /`� PARCEL#(OPTIONAO ADD EBB NEAREST CROSS S�E;:,T 1`i 6U y STATE ZIP CODE SITE PHONE%WITH AREA CODE CITY NAME K % n TOINDCPTE O CORPORATION INDIVIDUAL = PARTNERSHIP � DTLOCAL-AGENCY COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY TYPE OF BUSINESS ❑ 1 GAS STATION ICTS 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) ❑ RESERVATION O 3 FARM = 4 PROCESSOR 5 OTHER OR TRUST LANDS / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal DAYS: AME(LAST,FIRST) PHONE AREA DAYS: NAME ® 3_ -116,77] v M .cam KI o 20 Sr'L / ✓C NIGHTS: NAME(LAST, IRST) PHONE#W`ITH AREA COD/ NIGHTS: NAM (LAST,FIRST) q 3rj_ y rt r J -N // r I II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION NAME c It --Fk �� e ,/ box b indicate 0 INDIVIDUAL I0 LOCAL-AGENCY Q STATE-AGENCY MAILING O TREET ADD • Q O CORPORATION Q PARTNERSHIP O COUNTY-AGENCY O FEDEPA02/ L-AGENCY STATE ZIP CODE PHONE#WITH AREA CODE CITY NAM III. TANK OWNER INFORMATION•(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION LNAMEOFOWNER - — f e-- ✓ box b Win* = INDIVIDUAL O LOCAL—AGENCYlGENCV MAILINGOR STREETADDRESS O CORPORATION Q PARTNERSHIP [:7]COUNTY-AGENCY 0 FEDERAL-AGENCY STATE HONE#WITH AREA CODE CITY NAME IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HQ 4 4 - p Z o V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED Q 7SELF-INSURED I�2 GUARANTEE 3 INSURANCE L-1 a SURETY BOND ✓ box bintlicate 0 5 LETTER OFCREDn l�6 E%EMPTION W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II, IILC THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTHIDAWVEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# // FTIJESIN LOCATION CGDE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.A 5 FORM A(5-91)